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Friday, April 8, 2016

“Good enough for Government Work”: Quality, cost, and gaming the system, Part 1 (of 4 parts)

This is part one of the Charles Odegaard Lecture, delivered at the 27th National Conference on Primary Health Care Access, April 6, 2016

“The dream of reason did not
take power into account”.

--Paul Starr, "The Social Transformation of American Medicine", 1982

In 2008, the British Healthcare
Commission began an investigation into conditions at Stafford Hospital, run by
the Mid-Staffordshire Health Trust.[1]
The investigation was prompted by patient
complaints and a higher-than-expected death rate, and it and subsequent[2]
investigations uncovered a pattern of both poor quality care and cover-ups by
those running the hospital. It became a major national scandal. In 2014, whistleblowers
began to reveal the extent of problems in the Phoenix Veterans Administration
system, with long delays for appointments, inadequate care, and even excess deaths.
The
investigation revealed enormous cuts in services, as well as efforts to cover
up the problems, similar to those in Stafford. Moreover, it turned out that the
problem was far more extensive across the VA than just Phoenix.

These two events are discussed by
M. Gregg Bloche in his NEJM Perspective
“Scandal as a Sentinel Event —
Recognizing Hidden Cost–Quality Trade-offs”[3]. The details of the two scandals differ, as do the
health systems of the two countries in which they occurred, but there are
disturbing similarities.

“As with the VA scandal,” Bloche
writes, talking about Staffordshire, “politicians
blamed individual perpetrators and one another, and the prevailing narrative
highlighted lapses of character and culture…In both cases, performance
standards often proved incompatible with resource constraints….The fakery was
discovered, and perpetrators were punished. But the truth that trade-offs
between quality and cost were embedded in budget constraints remained
submerged.”

So, while more rigorous standards
were being set for performance, budgets were being cut. These cuts made it
difficult or impossible to meet those standards, and administrators in both
systems covered up the problems. They lied about their compliance with the
standards -- and, not coincidentally, often got financial bonuses for doing so
(or at least got to keep their jobs). In addition to the probably unnecessary
deaths, outcomes were more generally poor care for all patients. In the British
case, the excess deaths were pretty well documented, as were the stories of
patients lying in urine and excrement, inadequate food, and unavailable nursing
care. In the US, at the VA, proving excess deaths was more difficult, but
excessively long waits, particularly for specialty services, may well have
contributed to unnecessary or premature mortality, and falsifications by the
administrators were very clear.

In both cases, heads rolled – local
administrators, the head of the Mid-Staffordshire NHS Trust, and in the US
eventually the head of the VA. The politicians, in the US Congress and the British
Parliament, who had been responsible for the funding cuts in the first place,
took no responsibility and indeed used these scandals to act in a
self-righteous manner, denouncing “those responsible”, while being clear that
this did not include themselves. Nowhere in the discourse in the media are the
budget constraints and cutbacks acknowledged as a major cause of the problem.

And, yet, the politicians were surely
responsible, because it was the budget cuts that they imposed, along with the
potential they built in to these systems for financial gain on the part of
those directly tasked with running the operations, that led to these problems,
certainly along with the collusion of the people directly in charge. The process
has had two steps – first, we are going
to cut your funding and you are going to have to figure out how to cut in a way
that doesn’t, at least obviously and in a manner that reflects on us, cut
services. Second, we are going to tie rewards – institutional and personal (direct
financial bonuses, or at least keeping your jobs) – to the degree that you can
cut costs. We are also going, to a greater or lesser degree, “privatize”
operations on the assumption that this will, with the motivation of profit,
increase the efficiency (and lower the cost). And if we cannot privatize them,
we will use “motivators” characteristic of private enterprise – again see
financial bonuses. And now a right-wing group of Koch-funded consultants and
legislators is creating a proposal to essentially privatize the VHA, covered by
Suzanne Gordon,

“The
proposal they have crafted is an exercise in incoherence, denial, and magical
thinking. he group believes that private sector hospitals would be willing and
able to recreate VHA Centers of Excellence and other programs like the San
Francisco VAHCS’s Center of Excellence in Epilepsy or Primary Care Education or
Palo Alto’s polytrauma, blind or spinal cord injury rehabilitation programs. It
also believes the private sector could fulfill the VHA’s research and teaching
missions. As one San Francisco VAHCS researcher told me, “Can you see my eyes
rolling?”’http://suzannecgordon.com/the-plot-thickens/

It is of more than passing interest
that both of these events occurred in government agencies that were established
to provide necessary care to people. In Britain, the National Health Service,
established in 1948 to expand upon the National Health Insurance program that
had existed since prior to WW I, is enormously popular because it provides care
to everyone. Let’s think about this for a
minute. 1948 was soon after the war. Britain, as most of Europe (but not
the US) was in shambles, its population of young men decimated, its economy and
industrial capacity largely destroyed, its streets covered with rubble from the
Blitz (think the street scenes of East London in Call the Midwife from over a decade later), and the last thing that
they had was “extra money”.

But the National Health Service was established, not as largesse
in a time of plenty, but as a way of meeting the needs of the British people.
In the US, a different story unfolded; with its industrial capacity intact and
the need to shift from war to consumer production, the demand for labor
exceeded the number of workers. Prevented from increasing wages because of wage
and price controls, large companies found offering health insurance
(non-taxable) a significant inducement, and found common cause with labor
unions who could then offer these benefits to their members; a win-win that led
to the employer-based health system that has characterized the US since.

In Britain, the Mid-Staffordshire
scandal broke under a Labor government, but the seeds were sown when the
Conservatives were in control. Recognizing that the NHS was far too popular to
be dismantled, the Tories, seeking to emulate the US, both cut funding and
established “NHS Foundation Trusts”, like Mid-Staffordshire, which were in a
sense semi-privatized and incented to save money by being offered an
opportunity to keep some of the savings, which could be used both for
reinvestment in the hospitals and health system and to bonus those in charge. In
the US, our services to veterans have almost never (as documented by Bloche)
kept up with our rhetoric about the heroism of the men and women who serve in
our military, and the VA scandal was tightly linked to cuts in funding. Indeed,
some of the “solutions” offered by the same Congressmen who were responsible
for the cuts involved privatization; this is often proposed as a solution to
not having enough money, and almost never works, at least if the goal is
improving quality.

As Suzanne Gordon says in her piece
on the growing efforts in Washington to privatize the VA:

‘In their document, the Strawmen [the group
working on this] justify their position
on total privatization by pointing to the fact that the VHA is having trouble
hiring new recruits to fill many staff vacancies because of the “stigma”
attached to working at the VHA. They
also argue that the current VHA workforce suffers from “poor morale” and a
“culture of fear.” Of course, VHA management practices could be significantly
improved. But if there is now a “stigma”
attached to working at the VHA, a “culture of fear” within it, or
demoralization among its current employees, that is, in great part, due to the
bashing conservatives have unleashed in the media and Congress.’

1 comment:

Thanks so much for this post and for pointing to the culpability of the politicians.

It is important to understand these events as examples of Campbell's Law (https://en.wikipedia.org/wiki/Campbell%27s_law):

"The more any quantitative social indicator (or even some qualitative indicator) is used for social decision-making, the more subject it will be to corruption pressures and the more apt it will be to distort and corrupt the social processes it is intended to monitor."

This means that if you create a very high stakes measure of quality, people will meet that measure even if it means worsening the actual process. The New Yorker had a sad article in 2014, discussing how the pressure to produce high test scores in Georgia (if not schools would be closed, teachers would lose their jobs) led to massive cheating on the part of students and teachers. http://www.newyorker.com/magazine/2014/07/21/wrong-answer

We see this every day in EMR's which require us to fill in meaningless boxes in order to get our work done. This corrupts our professional ethic as physicians.

This is just one more way in which apparently "tough-minded business thinking" is just plain dumb and destructive.